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Practice Therapeutics

β blockers for heart failure with reduced ejection fraction

BMJ 2011; 343 doi: (Published 26 September 2011) Cite this as: BMJ 2011;343:d5603
  1. Derek G Waller, consultant cardiovascular physician1,
  2. James R Waller, specialty trainee year 4 cardiology2
  1. 1Southampton General Hospital, Southampton, SO16 6YD, UK
  2. 2Juba Teaching Hospital, Southern Sudan
  1. Correspondence to: D Waller derek.waller{at}

Case scenario

A 74 year old man attends the surgery for review of his longstanding heart failure. He has an exercise tolerance of just a few yards, limited by breathlessness. His jugular venous pressure is not raised, he has no ankle oedema, and the lung bases are clear. There is no evidence of fluid overload. A recent echocardiogram showed an ejection fraction of less than 25%. He has a history of type 2 diabetes mellitus and stage 2 chronic obstructive pulmonary disease with limited reversibility. His current treatment is with ramipril 10 mg daily and furosemide 80 mg daily, in addition to aspirin, simvastatin, and salbutamol and ipratropium inhalers. Should he be prescribed a β blocker?

Heart failure is characterised by neurohormonal activation, particularly of the sympathetic nervous system and the renin-angiotensin-aldosterone system.1 Reducing this activation with an angiotensin converting enzyme (ACE) inhibitor has been the mainstay of heart failure management for many years. β adrenoceptor antagonists (β blockers) used to be contraindicated in heart failure, owing to the risk of decompensation when they were given in doses licensed for treatment of angina or hypertension. However, raised concentrations of catecholamines in plasma (a marker of sympathetic nervous system activation) correlate with disease severity, disease progression, and a poorer prognosis, and may therefore contribute to deterioration of cardiac function.2 3 Re-evaluation of the potential for low dose β blockers to ameliorate these consequences showed overwhelmingly that they reduce morbidity and mortality in heart failure with reduced left ventricular ejection fraction (LVEF). These drugs are now a cornerstone of effective management of symptoms and prognosis.3

Three β blockers are licensed in the UK for treatment of heart failure: carvedilol, bisoprolol, and nebivolol. Carvedilol is a non-selective β blocker and has vasodilatory effects owing to α1 adrenoceptor blockade. The other two drugs …

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